Fluid Management With a Simplified Conservative Protocol for the Acute Respiratory Distress Syndrome*

Abstract

Objectives In the Fluid and Catheter Treatment Trial (FACTT) of the National Institutes of Health Acute Respiratory Distress Syndrome Network, a conservative fluid protocol (FACTT Conservative) resulted in a lower cumulative fluid balance and better outcomes than a liberal fluid protocol (FACTT Liberal). Subsequent Acute Respiratory Distress Syndrome Network studies used a simplified conservative fluid protocol (FACTT Lite). The objective of this study was to compare the performance of FACTT Lite, FACTT Conservative, and FACTT Liberal protocols. Design Retrospective comparison of FACTT Lite, FACTT Conservative, and FACTT Liberal. Primary outcome was cumulative fluid balance over 7 days. Secondary outcomes were 60-day adjusted mortality and ventilator-free days through day 28. Safety outcomes were prevalence of acute kidney injury and new shock. Setting ICUs of Acute Respiratory Distress Syndrome Network participating hospitals. Patients Five hundred three subjects managed with FACTT Conservative, 497 subjects managed with FACTT Liberal, and 1,124 subjects managed with FACTT Lite. Interventions Fluid management by protocol. Measurements and Main Results Cumulative fluid balance was 1,918 ± 323 mL in FACTT Lite, −136 ±491 mL in FACTT Conservative, and 6,992 ± 502 mL in FACTT Liberal (p < 0.001). Mortality was not different between groups (24% in FACTT Lite, 25% in FACTT Conservative and Liberal, p = 0.84). Ventilator-free days in FACTT Lite (14.9 ±0.3) were equivalent to FACTT Conservative (14.6±0.5) (p = 0.61) and greater than in FACTT Liberal (12.1 ±0.5, p < 0.001 vs Lite). Acute kidney injury prevalence was 58% in FACTT Lite and 57% in FACTT Conservative (p = 0.72). Prevalence of new shock in FACTT Lite (9%) was lower than in FACTT Conservative (13%) (p = 0.007 vs Lite) and similar to FACTT Liberal (11%) (p = 0.18 vs Lite). Conclusions FACTT Lite had a greater cumulative fluid balance than FACTT Conservative but had equivalent clinical and safety outcomes. FACTT Lite is an alternative to FACTT Conservative for fluid management in Acute Respiratory Distress Syndrome.

Fluid Therapy: Double-Edged Sword during Critical Care?

“…Aggressive initial treatment followed by a restrictive approach was demonstrated to be beneficial by Murphy et al [ 95 ]. In ARDS patients FACTT [ 96 ] and recent FACTT lite trials [ 97 ] demonstrated that restrictive maintenance in stabilization phase was associated with improvement in outcome. It is of vital importance to recognize the right moment to stop the optimization, but unfortunately we possess no evidence based data to elucidate this critical moment.…”

Impact of Initial Central Venous Pressure on Outcomes of Conservative Versus Liberal Fluid Management in Acute Respiratory Distress Syndrome

“…Application of the trial’s results to practice has focused on the administration of diuretics to patients with elevated CVP, with no protocolized intervention for those with a low CVP(24). Our results contrast with that approach.…”

Fluid management in acute kidney injury

“…Hypothetically, this could be related to transient episodes of cerebral hypoperfusion during fluid removal [73], as there was a higher incidence of "new shock" in the conservative arm. Recently a simpler "FACCT-LITE" fluid strategy has been described [74]. This approach was associated with similar respiratory and renal outcomes compared to the conservative group in FACCT, but with a "new shock" rate similar to the liberal arm, suggesting the value of haemodynamic stability for fluid removal emphasised in this regimen.…”